Background/Objectives: Impella 5.5 provides a higher flow rate than smaller microaxial pumps and has been increasingly adopted for cardiogenic shock (CS). This study aimed to evaluate whether its introduction into our Shock Team program in 2023 improved outcomes compared with a historical cohort supported with other mechanical circulatory support (MCS) devices. Methods: We retrospectively analyzed patients with CS treated with MCS between 2020 and 2024 at a tertiary center. The Impella 5.5 group (n = 17) included patients managed after device implementation, either as stand-alone or sequential therapy. The historical cohort comprised 40 patients treated with ECMO, Impella CP, CentriMag, or IABP prior to 2023. Propensity score matching (age, sex, etiology, lactate, SCAI stage) generated 17 matched pairs. The primary outcome was survival at discharge, 30 days, 3 months, and 6 months. Secondary outcomes included bridging to recovery, heart transplantation (HTx), durable LVAD, and major complications. Results: Impella 5.5 was associated with higher survival at discharge (94.1% vs. 58.8%, p = 0.039), 30 days (94.1% vs. 58.8%, p = 0.039), and 3 months (94.1% vs. 58.8%, p = 0.039). At 6 months, survival remained higher (88.2% vs. 58.8%) but did not reach statistical significance in point analysis (p = 0.118). Bridging occurred more frequently with Impella 5.5 (HTx 64.7% vs. 52.9% (p = 0.464), recovery 17.6% vs. 5.9% (p = 0.292)), while LVAD implantation rates were similar (11.8% vs. 17.6%, p = 1.0). Major bleeding (17.6% vs. 47.1%, p = 0.141), stroke/TIA (5.9% vs. 17.6%, p = 0.601), and the need for renal replacement therapy (5.9% vs. 23.5%, p = 0.335) were numerically lower with Impella 5.5. Conclusions: In this single-center, retrospective analysis, the introduction of Impella 5.5 was associated with higher short-term survival and favorable bridging metrics; estimates are imprecise due to small, heterogeneous samples. These hypothesis-generating findings warrant confirmation in larger, prospective multicenter cohorts

BACKGROUND:Coronary artery revascularization is vital for managing coronary artery disease, especially in elderly patients with multiple comorbidities. AIMS:To evaluate the outcomes of coronary artery bypass surgery in patients aged ≥75 years, focusing on the survival benefits of different surgical techniques and graft types. MATERIAL AND METHODS:This retrospective cohort study analyzed data from the Polish National Registry of Cardiac Surgery Procedures (2012-2022) for patients aged ≥75 years undergoing isolated coronary artery bypass surgery. RESULTS:We analysed 18 215 patients: 12 843 patients were under 80 years old; 4689 were between 80 and 84 years old; and 683 were ≥85 years old. Key preoperative risk factors associated with increased hospital mortality included extracardiac arteriopathy, atrial fibrillation, chronic renal failure, recent myocardial infarction, and poor mobility. The median follow-up time was 4.8 years (interquartile range 2.37-7.27). On-pump coronary artery bypass grafting (ONCAB) demonstrated a significant long-term benefit in patients aged <80 years. The use of an internal mammary artery graft provided significant survival advantages for those <85 years old, but this benefit was not observed in patients aged ≥85 years (P = 0.73). Multiarterial grafting did not demonstrate a significant survival advantage across all age groups. CONCLUSIONS:In patients ≥80 years old there was no survival benefit between ONCAB and off-pump coronary bypass grafting. However, ONCAB was associated with significantly improved survival outcomes in younger patients. The internal mammary artery graft improved long-term survival in patients <85 years old, while additional arterial grafts did not confer a survival benefit in the elderly population.

OBJECTIVES This study aimed to compare perioperative outcomes and long-term mortality between off-pump coronary artery bypass grafting and on-pump coronary artery bypass grafting in patients with ischaemic cardiomyopathy who had a left ventricle ejection fraction of <= 35%.METHODS A retrospective cohort analysis was conducted using data from the Polish National Registry of Cardiac Surgery Procedures database, encompassing patients who underwent isolated coronary artery bypass grafting in Poland between 2012 and 2022. Patients were divided into two groups: on-pump and off-pump. Propensity score matching was used to balance the groups. The primary outcome was long-term all-cause mortality following surgical revascularization.RESULTS A total of 9920 patients were included, with 3116 patients in each group after propensity score matching. The median follow-up period was 4 years. The off-pump group was associated with a lower 30-day mortality rate (6.4% vs 9.1%, P = 0.002) and fewer perioperative complications. However, long-term survival analysis revealed a modest but statistically significant advantage for on-pump group at the 10-year follow-up (P = 0.047).CONCLUSIONS Off-pump provides short-term benefits, including reduced early mortality and fewer complications compared to on-pump technique. However, these advantages do not translate into improved long-term survival, where on-pump demonstrates a slight benefit. The choice between off-pump and on-pump technique should be individualized based on patient-specific factors and surgical expertise. Ischaemic cardiomyopathy (ICM) manifests as reduced left ventricle ejection fraction (LVEF) due to acute or acute on chronic coronary artery disease, posing a significant global health challenge [1].

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Results of bicuspid aortic valve (BAV) repair in different configurations related to coexisting aortopathy are currently in the spotlight. The recent article by Svensson and colleagues1Svensson L.G. Rosinski B.F. Miletic K. Hodges K. Rajeswaran J. Griffin B. et al.Effect of ascending aorta replacement on the long-term outcomes of bicuspid aortic valve repair.J Thorac Cardiovasc Surg. March 2, 2023 [Epub ahead of print]; https://doi.org/10.1016/j.jtcvs.2023.02.024Abstract Full Text Full Text PDF Scopus (1) Google Scholar puts together impressive data collected over 22 years into a landmark study supported by state-of-the-art statistics. The study included 840 patients who underwent BAV repair alone or with ascending aorta replacement and investigated whether sinotubular junction (STJ) remodeling provided by ascending aorta replacement benefits the repair durability. Results were analyzed using propensity score matching with 97 pairs generated. The authors concluded that stabilization of STJ at the time of BAV repair had minimal influence on repair durability. We find this takeaway message too presumptous in the context of recently published data. The benefit of STJ remodeling on repair durability has been shown by many: Shraer and colleagues2Shraer N. Youssefi P. Zacek P. Debauchez M. Leprince P. Raisky O. et al.Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplasty.J Thorac Cardiovasc Surg. November 24, 2022; https://doi.org/10.1016/j.jtcvs.2022.11.021Abstract Full Text Full Text PDF Scopus (4) Google Scholar (343 patients) and Jasinski and colleagues3Jasinski M.J. Kosiorowska K. Gocol R. Jasinski J. Nowicki R. Bielicki G. et al.Bicuspid aortic valve repair: outcomes after 17 years of experience.Eur J Cardio Thorac Surg. 2021; 60: 1053-1061Crossref PubMed Scopus (17) Google Scholar (206 patients) both present 17 years of outcomes. The discussion highlighting the importance of functional aortic annulus (FFA) stabilization as a concept of BAV repair has been published this year, and is illustrated in Figure 1.4Jasinski M. Aortic annuloplasty during bicuspid aortic valve repair: simple is ok but not simpler (quote Einstein).J Thorac Cardiovasc Surg Open. January 13, 2023 [Epub ahead of print]; https://doi.org/10.1016/j.xjon.2023.01.003Abstract Full Text Full Text PDF Scopus (1) Google Scholar,5Youssefi P. Debauchez M. Lansac E. Reply: what is a good annuloplasty for bicuspid aortic valve repair.J Thorac Cardiovasc Surg Open. February 10, 2023 [Epub ahead of print]; https://doi.org/10.1016/j.xjon.2023.02.003Abstract Full Text Full Text PDF Google Scholar Notably, the freedom from aortic valve reoperation favored the STJ remodeling group before the matching and almost reached significance for the matched cohort (P = .08). Moreover, more than three-quarters of the study population was not matched, creating a considerable risk of selection bias and questioning the ability of the analysis to detect the importance of STJ remodeling. We believe the authors' conclusions should be more cautious. Remodeling the entire FAA during BAV repair may also specifically address another element of repair durability: Elevated postoperative gradient, a unique phenomenon after BAV repair. Several clinical articles presenting relevant data on this issue have been published within the past 2 years.6Patlolla S.H. Saran N. Dearani J. Stulak J. Schaff H. Greason K. et al.Outcomes and risk factors of late failure of valve sparing root replacement.J Thorac Cardiovasc Surg. 2022; 164: 493-501.e1Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 7Patlolla S.H. Schaff H.V. Stulak J.M. Michelena H.I. Saran N. King K.S. et al.Bicuspid aortic valve repair: causes of valve failure and long-term outcomes.Ann Thorac Surg. 2021; 111: 1225-1232Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 8Roselli E. Thompson M. Yazdchi F. Lowry A. Johnston D. Desai M. et al.Well- functioning BAV should be preserved during aortic replacement for the ascending aortopathy phenotype.J Thorac Cardiovasc Surg. May 15, 2022 [Epub ahead of print]; https://doi.org/10.1016/j.jtcvs.2022.05.001Abstract Full Text Full Text PDF Scopus (3) Google Scholar In line with those, Svensson and colleagues1Svensson L.G. Rosinski B.F. Miletic K. Hodges K. Rajeswaran J. Griffin B. et al.Effect of ascending aorta replacement on the long-term outcomes of bicuspid aortic valve repair.J Thorac Cardiovasc Surg. March 2, 2023 [Epub ahead of print]; https://doi.org/10.1016/j.jtcvs.2023.02.024Abstract Full Text Full Text PDF Scopus (1) Google Scholar describe postoperative gradient elevations that are significantly higher in patients with solitary BAV repair after the matching. What could be the reason? Limited mobility of fused leaflets is among the factors related to the higher gradient. Roselli and colleagues8Roselli E. Thompson M. Yazdchi F. Lowry A. Johnston D. Desai M. et al.Well- functioning BAV should be preserved during aortic replacement for the ascending aortopathy phenotype.J Thorac Cardiovasc Surg. May 15, 2022 [Epub ahead of print]; https://doi.org/10.1016/j.jtcvs.2022.05.001Abstract Full Text Full Text PDF Scopus (3) Google Scholar showed that the calibrated elasticity index influences both the gradient and repair durability. Several techniques address the whole FFA complex, enhancing the leaflets' mobility, with STJ remodeling being an essential part.2Shraer N. Youssefi P. Zacek P. Debauchez M. Leprince P. Raisky O. et al.Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplasty.J Thorac Cardiovasc Surg. November 24, 2022; https://doi.org/10.1016/j.jtcvs.2022.11.021Abstract Full Text Full Text PDF Scopus (4) Google Scholar,9de Kerchove L. Boodhwani M. Glineur D. Vandyck M. Vanoverschelde J.L. Noirhomme P. et al.Valve sparing-root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair.J Thorac Cardiovasc Surg. 2011; 142: 1430-1438Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar,10Jasinski M. Deja M. Kosiorowska K. Gocol R. Rankin S. Internal aortic annuloplasty remodeling ring in bicuspid aortic valve repair: different phenotypes.Multimed Man Cardiothorac Surg. 2022; 22: 2022Google Scholar Reverse-gradient dynamics and their decrease in time have been illustrated,2Shraer N. Youssefi P. Zacek P. Debauchez M. Leprince P. Raisky O. et al.Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplasty.J Thorac Cardiovasc Surg. November 24, 2022; https://doi.org/10.1016/j.jtcvs.2022.11.021Abstract Full Text Full Text PDF Scopus (4) Google Scholar,3Jasinski M.J. Kosiorowska K. Gocol R. Jasinski J. Nowicki R. Bielicki G. et al.Bicuspid aortic valve repair: outcomes after 17 years of experience.Eur J Cardio Thorac Surg. 2021; 60: 1053-1061Crossref PubMed Scopus (17) Google Scholar which may explain the authors' findings of higher gradients in patients with BAV repair alone. We congratulate the authors for presenting outstanding large-volume data. However, the results regarding the low benefits of STJ remodeling are not entirely clear and should be interpreted with caution. There are many questions on BAV repair durability that are as yet unanswered.

M.J. Jasinski has a relationship with Biostable. All other authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. M.J. Jasinski has a relationship with Biostable. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Results of aortic root replacement in patients with Marfan syndrome undergoing either valve-sparing root replacement in the form of aortic valve sparing reimplantation (AVS) or root replacement (AVR) have again come into the spotlight. The article by Cosselli and colleagues1Coselli J.S. Volguina I.V. LeMaire S.A. Connolly H.M. Sundt T.M. Milewicz D.M. et al.Midterm outcomes of aortic root surgery in patients with Marfan syndrome: a prospective, multicenter, comparative study.J Thorac Cardiovasc Surg. 2023; 165: 1790-1799Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar gathers data collected during 3 years of planned follow-ups of a prospective registry of 316 patients, primarily trileaflet, undergoing operation between 2005 and 2010. Survival was comparable during the median follow-up of 64 months (88.2% vs 95.0% in AVR and AVS, respectively). However, after propensity score-adjusted competing risk modeling, the authors found an association between AVS and cumulative incidence of moderate insufficiency (hazard ratio [HR], 48.28) and non structural valve deterioration + structural valve deterioration (HR, 12.95). Likewise, AV-related morbidity and major adverse valve related events were higher in the AVS group (HR, 3.54 and 2.34, respectively). Considering the relevant rate of moderate (+) insufficiency in the AVS group, a closer examination of the underlying factors contributing to failure may yield valuable insights. In the context of recently published data, aortic regurgitation recurrence in AVS of patients with Marfan syndrome with durable leaflet repair could be an effect of nonideal annuloplasty during reimplantation.2Svensson L.G. Vargo P.R. Desai M.Y. Kalahasti V. Griffin B. Roselli E.E. et al.Aortic valve reimplantation in patients with connective tissue disorders: are the leaflets durable?.J Thrac Cardiovasc Surg. November 24, 2022; ([Epub ahead of print]. https://doi.org/10.1016/j.jtcvs.2022.11.019)Abstract Full Text Full Text PDF Scopus (1) Google Scholar,3Elbatarny M. David T.E. David C.M. Chung J.C.Y. Lafrenier-Roula M. Ouzounian M. Improved outcomes of reimplantation vs remodeling in Marfan syndrome: a propensity-matched study.Ann Thorac Surg. 2023; 115: 576-582Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Findings show that despite deep root dissection and complete annuloplasty, the ventricle aortic junction and the polyethylene terephthalate prosthesis interference were inconsistent along the entire annular circumference. Moreover, annular dimensions increase after reimplantation as the aortic annulus becomes more ellipsoid, regaining its preoperative shape.4Giosu e Irace F. Chirichilli I. Salica A. D’Aleo S. Wolf L.G. Garufi L. et al.Aortic root anatomy after aortic valve reimplantation.J Thorac Cardiovasc Surg. 2023; 165: 1335-1342Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar,5Jasinski M, Nowicki R, Kansy A. Functional Aortic Annulus 3D Remodeling during Bicuspid Aortic Valve Repair. Complete External and Internal Annuloplasty, multimed. Man Cardithorac Surg. 2023 Jun 07:2023. https://doi.org/10.1510/mmcts.2023.014Google Scholar Thus, stabilizing the virtual basal ring seems critical in securing repair.5Jasinski M, Nowicki R, Kansy A. Functional Aortic Annulus 3D Remodeling during Bicuspid Aortic Valve Repair. Complete External and Internal Annuloplasty, multimed. Man Cardithorac Surg. 2023 Jun 07:2023. https://doi.org/10.1510/mmcts.2023.014Google Scholar Furthermore, the approximation of both planes may determine the physiologic perpendicular flow direction during the cardiac cycle, as seen in the cardiac magnetic resonance reconstruction in Figure 1, A.6Jasinski M.J. Miszalski-Jamka K. Kosiorowska K. Gocol R. Wenzel-Jasinska I. Bielicki G. et al.The evaluation of annuloplasty in bicuspid aortic valve repair using cardiac magnetic resonance.BMC Cardiovasc Disord. 2021; 21 (Erratum in: BMC Cardiovasc Disord. 2021;21:89): 13Crossref PubMed Scopus (8) Google Scholar We should address 3 elements to improve postoperative anatomy and valve function. First, circumferential and complete virtual basal ring stabilization may be better achieved with complete internal annuloplasty in the form of a ring or full line of pledged sutures incorporated into valve-sparing root replacement because it may counteract the dilatation of the muscular annulus, which is responsible for annular enlargement, according to El-Khoury and colleagues.7Sievers H.H. Repair follows anatomy.J Thorac Cardiovasc Surg. 2018; 156: 588-589Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 8Stavridis G.T. Downey R.S. Gerdisch M.W. Hughes G. Jasinski M.J. Rankin J.S. et al.Aortic valve repair for tri-leaflet aortic insufficiency associated with asymmetric aortic root aneurysms.Ann Cardiothorac Surg. 2019; 8: 426-429Crossref PubMed Scopus (12) Google Scholar, 9Nawaytou O. Mastrobuoni S. de Kerchove L. Baert J. Boodhwani M. El Khoury G. Deep circumferential annuloplasty as an adjunct to repair regurgitant bicuspid aortic valves with a dilated annulus.J Thorac Cardiovasc Surg. 2018; 156: 590-597Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Second, circumferential and continuous annuloplasty of the fibrotic annulus may provide further stability, preventing dilatation due to annual-aortic ectasia, typically found in patients with Marfan syndrome.3Elbatarny M. David T.E. David C.M. Chung J.C.Y. Lafrenier-Roula M. Ouzounian M. Improved outcomes of reimplantation vs remodeling in Marfan syndrome: a propensity-matched study.Ann Thorac Surg. 2023; 115: 576-582Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Lastly, re-establishing the physiological 3-dimensional shape of the functional aortic annulus and symmetrical commissural orientation of 120° is also essential.2Svensson L.G. Vargo P.R. Desai M.Y. Kalahasti V. Griffin B. Roselli E.E. et al.Aortic valve reimplantation in patients with connective tissue disorders: are the leaflets durable?.J Thrac Cardiovasc Surg. November 24, 2022; ([Epub ahead of print]. https://doi.org/10.1016/j.jtcvs.2022.11.019)Abstract Full Text Full Text PDF Scopus (1) Google Scholar An elliptical annuloplasty ring may help bring leaflets together at the midline, increasing the coaptation surface, a technique shown to be applicable to root remodeling.8Stavridis G.T. Downey R.S. Gerdisch M.W. Hughes G. Jasinski M.J. Rankin J.S. et al.Aortic valve repair for tri-leaflet aortic insufficiency associated with asymmetric aortic root aneurysms.Ann Cardiothorac Surg. 2019; 8: 426-429Crossref PubMed Scopus (12) Google Scholar,10Jasinski M.J. Rankin J.S. Aortic valve annuloplasty with the HAART geometric ring and ascending aorta replacement.Multimed Man Cardiothorac Surg. 2018; 2018https://doi.org/10.1510/mmcts.2018.024Crossref Scopus (3) Google Scholar,11Gerdisch M.W. Reece T.B. Emerson D. Downey R.S. Blossom G.B. Singhal A. et al.the BAVr Working GroupEarly results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery.JTCVS Tech. 2022; 14: 55-60Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar The utilization of these techniques may be considered an adjunct to annuloplasty during either remodeling or reimplantation, as schematically illustrated in Figure 1, B. We commend the authors for their outstanding effort in publishing these exciting data. Although some results favored AVR, we should remember that the follow-up is relatively short, and age-adjusted survival almost reached significance in favor of the AVS group. Ultimately, this presents a valuable opportunity to investigate the various aspects of AV repair and annuloplasty techniques. We must stay open-minded to changes because the real game-changers often lie in the details. Commentary: The issue of pacemaker implantation after surgical ablation for atrial fibrillationThe Journal of Thoracic and Cardiovascular SurgeryVol. 166Issue 3PreviewIn recent years the issue of permanent pacemaker implantation (PPMI) after surgical ablation for atrial fibrillation (AF), and the Cox maze procedure in particular, is readily discussed and debated. Although this topic is of significance, I find that the current discussion often lacks the granularity required to improve our understanding. Full-Text PDF

The authors reported Consultant to Biostable.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported Consultant to Biostable. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. “blood…percusses against the front of the arches of the hemicycles (sinus), and follows the concavity of this hemicycle, until it percusses against the concavity at the base of this hemicycle (cusps)”— Leonardo da Vinci, glass model of aortic valve 1507-08.The study by Yerokun and colleagues1Yerokun B. Vallabhajosyula P. Vekstein A. Grau-Sepulveda M.V. Benrashid E. Xian Y. et al.Long-term outcomes of aortic root operations in the United States among Medicare beneficiaries.J Thorac Cardiovasc Surg. 2023; 165: 554-565https://doi.org/10.1016/j.jtcvs.2021.02.068Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar reports midterm risk-adjusted survival and clinical outcome by aortic root replacement (ARR) strategy in 4173 Medicare beneficiaries, 65 years or older, based on the Society of Thoracic Surgeons Database. At 7 years, survival was significantly lower after mechanical ARR than stentless and stented ARR. However, the stentless ARR strategy also presented superiority in secondary end points, including freedom from stroke, which was identical to valve-sparing root replacement but had a significantly lower redo rate. Likewise, readmissions due to bleeding were the lowest in this group. The authors should be congratulated on a successfully established and well-conducted contemporary, retrospective, high-volume study based on the benchmark Society of Thoracic Surgeons Database, which may be essential to the decision-making process in the future. However, the clear superiority of stentless root replacement has not been highlighted. Instead, recommendations were based on the easy potential for the valve-in-valve procedure after stented ARR. Renewed interest in stentless root-replacement strategy is well illustrated by multicenter clinical data proving its versatile applicability.2Dagnegard H. Bekke K. Kolseth S. Glaser N. Wallén C. El-Hamamsy I. et al.Survival after aortic root replacement with a stentless xenograft is determined by patient characteristics.J Thorac Cardiovasc Surg. 2022; 164: 1712-1724.e10Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Randomized long-term data confirm superior durability and valve function over homografts, with survival equivalent to matched population and valve function to autografts.3Melina G. De Robertis F. Gaer J.A. Angeloni E. El-Hamamsy I. Bahrami T. et al.Long-term survival after xenograft versus homograft aortic root replacement: results from a prospective randomized trial.J Thorac Cardiovasc Surg. 2021; 161: 57-65Abstract Full Text Full Text PDF Scopus (11) Google Scholar The superiority of stentless implantation lies in lower gradients and larger effective orifice area, and it has been confirmed in randomized studies.4Perez de Arenaza D. Lees B. Flather M. Nugara F. Husebye T. Jasinski M. et al.ASSERT (Aortic Stentless versus Stented valve assessed by Echocardiography Randomized Trial) InvestigatorsA randomised comparison of stentless versus stented valves for aortic stenosis: effects on left ventricular mass.Circulation. 2005; 112: 2696-2702Crossref PubMed Scopus (88) Google Scholar,5Jasinski M. Kolowca M. Woś S. Stentless Implantation: From Hemodynamics to Remodelling. Habilitation Theses. Advances and Controversies in Adult Heart Valve Surgery. Wroclaw: Urban & Partner, 2012: 83-91Google Scholar A recent comparison of 340 ARR versus 193 root enlargements for aortic valve stenosis also has shown better hemodynamics in stentless ARR.6Yousef S. Serna-Gallegos D. Brown J.A. Ogami T. Wang Y. Thoma F.W. et al.Outcomes of root enlargement versus root replacement for aortic stenosis.Ann Thorac Surg. 2023; https://doi.org/10.1016/j.athoracsur.2022.12.027Abstract Full Text Full Text PDF Scopus (2) Google Scholar The risk of neoroot dilatation and pseudoaneurysm discussed by the authors evoked advancements in implantation techniques milieu, adding elements of wrapping to the procedure, well documented in the literature on ARR with autografts.7Starnes V.A. Elsayed R.S. Cohen R.G. Olds A.P. Bojko M.M. Mack W.J. et al.Long-term outcomes with the pulmonary autograft inclusion technique in adults with bicuspid aortic valves undergoing the Ross procedure.J Thorac Cardiovasc Surg. 2023; 165: 43-52Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar In addition, stentless ARR offers much technical versatility. A modified “cylinder within cylinder root replacement” that I have published recently may reduce the operative risk and eliminate the issue of porcine root dilatation but not compromise the sizing strategy and hemodynamics at the same time.8Jasinski M. Stentless cylinder-within-a-cylinder reimplantation: modified inclusion root replacement.Multimed Man Cardiothorac Surg. 2022; https://doi.org/10.1510/mmcts.2022.098Crossref Scopus (1) Google Scholar Clinically proven hemodynamical superiority, so relevant during exercise, should remain an essential argument during the decision-making process, bearing in mind the increasingly active life-style of society.9Khoo J.P. Davies J.E. Ang K.L. Galiñanes M. Chin D.T. Differences in performance of five types of aortic valve prostheses: hemodynamic assessment by dobutamine stress echo.Heart. 2013; 99: 41-47Crossref PubMed Scopus (15) Google Scholar Stentless ARR, proven by recent data and unique technical versatility, deserves to remain a contemporary benchmark operation.10Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.Circulation. 2021; 143: e35-e71PubMed Google Scholar Long-term outcomes of aortic root operations in the United States among Medicare beneficiariesThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2PreviewThe best method of aortic root repair in older patients remains unknown given a lack of comparative effectiveness of long-term outcomes data. The objective of this study was to compare long-term outcomes of different surgical approaches for aortic root repair in Medicare patients using The Society of Thoracic Surgeons Adult Cardiac Surgery Database-Centers for Medicare & Medicaid Services–linked data. Full-Text PDF Reply from the authors: Stentless versus stented bioprosthetic root replacement in the medicare population and the wisdom of crowdsThe Journal of Thoracic and Cardiovascular SurgeryVol. 166Issue 2PreviewIn our recent analysis of long-term outcomes of aortic root operations in the United States among Medicare beneficiaries using the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD) and Centers for Medicare and Medicaid Services linked data for patients aged 65 years or older undergoing elective aortic root surgery, we concluded that the bioprosthetic Bentall operation should be the procedure of choice in this population due to improved survival and lower stroke risk compared with the use of the mechanical Bentall, and lower risk of aortic valve reintervention compared with valve-sparing aortic root replacement. Full-Text PDF

Disclosures: M.J.J. is a consultant for BioStable.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Disclosures: M.J.J. is a consultant for BioStable. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. An elevated gradient is a unique feature after bicuspid aortic valve (BAV) repair and may have been underrecognized as a clinical problem. However, during a short time span, it has been recently reported by several groups in the Journal. The association of higher BAV gradients after valve-sparing root replacement and BAV repair compared with tricuspid aortic valve repair was described by Mokashi and colleagues1Mokashi S. Rosinski B. Desai M. Griffin B. Hammer D. Kalahastii V. et al.Aortic root replacement with BAV reimplantation.J Thorac Cardiovasc Surg. 2022; 163: 51-63Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar and confirmed by Patlolla and colleagues.1Mokashi S. Rosinski B. Desai M. Griffin B. Hammer D. Kalahastii V. et al.Aortic root replacement with BAV reimplantation.J Thorac Cardiovasc Surg. 2022; 163: 51-63Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 2Patlolla S.H. Saran N. Dearani J. Stulak J. Schaff H. Greason K. et al.Outcomes and risk factors of late failure of valve sparing root replacement.J Thorac Cardiovasc Surg. 2022; 164: 493-501.e1Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar They reported elevated gradients at different time points during follow-up and a gradual increase of the frequency. Patlolla and colleagues1Mokashi S. Rosinski B. Desai M. Griffin B. Hammer D. Kalahastii V. et al.Aortic root replacement with BAV reimplantation.J Thorac Cardiovasc Surg. 2022; 163: 51-63Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 2Patlolla S.H. Saran N. Dearani J. Stulak J. Schaff H. Greason K. et al.Outcomes and risk factors of late failure of valve sparing root replacement.J Thorac Cardiovasc Surg. 2022; 164: 493-501.e1Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar reported that valve stenosis–related redo operations were unique for BAV repairs and responsible for 62% of them. Mokashi and colleagues1Mokashi S. Rosinski B. Desai M. Griffin B. Hammer D. Kalahastii V. et al.Aortic root replacement with BAV reimplantation.J Thorac Cardiovasc Surg. 2022; 163: 51-63Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar reported gradually increased gradient during follow-up. The same groups reported increased gradients postoperatively for isolated BAV repair, as described by Roselli and colleagues3Roselli E. Thompson M. Yazdchi F. Lowry A. Johnston D. Desai M. et al.Well- functioning BAV should be preserved during aortic replacement for the ascending aortopathy phenotype.J Thorac Cardiovasc Surg. 2022; https://doi.org/10.1016/j.jtcvs.2022.05.001Abstract Full Text Full Text PDF Scopus (3) Google Scholar and Patlolla and colleagues.4Patlolla S.H. Schaff H.V. Stulak J.M. Michelena H.I. Saran N. King K.S. et al.Bicuspid aortic valve repair: causes of valve failure and long-term outcomes.Ann Thorac Surg. 2021; 111: 1225-1232Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Of note, 68% of reoperations were related to significantly elevated gradients and development of severe aortic valve stenosis, a percentage similar to that reported for valve-sparing root replacement. Additionally, the longitudinal analysis showed an increase in gradients during follow-up. The majority of patients received subcommissural annuloplasty. Therefore, it can be assumed that the annuloplasty technique may have influenced the postoperative gradient and patient outcomes. Our group reported a prospective head-to-head comparison of subcommissural and external circumferential annuloplasty using cardiac magnetic resonance and transthoracic echocardiography,5Jasinski M.J. Miszalski-Jamka K. Kosiorowska K. Gocol R. Wenzel-Jasinska I. Bielicki G. et al.The evaluation of annuloplasty in bicuspid aortic valve repair using cardiac magnetic resonance.BMC Cardiovasc Disord. 2021; 21 (Erratum in: BMC Cardiovasc Disord. 2021;21:89): 13https://doi.org/10.1186/s12872-020-01831-4Crossref PubMed Scopus (8) Google Scholar,6Jasinski M. Pysz P. Plonek T. Gocol R. Hudziak D. Kansy A. et al.BAV repair with external or sucommissural annuloplasty.J Card Surg. 2021; 37: 526-531https://doi.org/10.1111/jocs.16154Crossref PubMed Scopus (3) Google Scholar proving a significant correlation of gradient and subcommisural annuloplasty. On the other hand, a significant decrease after circumferential annuloplasty was revealed in long-term transthoracic echocardiography data, a trend depicted in Figure 1.7Jasinski M.J. Kosiorowska K. Gocol R. Jasinski J. Nowicki R. Bielicki G. et al.Bicuspid aortic valve repair: outcomes after 17 years of experience.Eur J Cardiothorac Surg. 2021; 60: 1053-1061Crossref PubMed Scopus (20) Google Scholar Likewise, Shraer and colleagues8Shraer N. Youssefi P. Zacek P. Debauchez M. Leprince P. Raisky O. et al.Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplasty.J Thorac Cardiovasc Surg. 2022; https://doi.org/10.1016/j.jtcvs.2022.11.021Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar from the Lansac group found that simultaneous circumferential annuloplasty of annular horizontal plane and sinotubular junction aiming at 180 symmetry shows sustained gradients over time. Stenosis after BAV repair was analyzed by the Brussels group and reported by Spadacio and colleagues.9Spadacio C. Nenna A. Henkens A. Mastroubuoni S. Jahanyar J. Aphram G. et al.Predictors of long term stenosis in BAV repair.J Thorac Cardiovasc Surg. 2022; : 1-11https://doi.org/10.1016/j.jtcvs.2022.04.024Google Scholar They concluded that the level of complexity of repair or use of polytetrafluoroethylene (Gore-Tex, WL Gore & Associates, Inc, Flagstaff, Ariz) predicted the development of severe stenosis and a redo operation. Complex leaflet repair has been confirmed as a negative predictor of durability in a previous authors study.10Jasinski M.J. Gocol R. Malinowski M. Hudziak D. Duraj P. Deja M.A. Predictors of early and medium-term outcome of 200 consecutive aortic valve and root repairs.J Thorac Cardiovasc Surg. 2015; 149: 123-129Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Efforts to minimize postrepair gradients are being undertaken. An interesting concept of estimating the leaflet pliability as Tissue Normality Index (TNI), presented by the Cleveland group during 2022 AATS meeting may help to define tissue quality and avoid higher postoperative gradients.3Roselli E. Thompson M. Yazdchi F. Lowry A. Johnston D. Desai M. et al.Well- functioning BAV should be preserved during aortic replacement for the ascending aortopathy phenotype.J Thorac Cardiovasc Surg. 2022; https://doi.org/10.1016/j.jtcvs.2022.05.001Abstract Full Text Full Text PDF Scopus (3) Google Scholar On the other hand, when reducing the annulus by annular remodeling, the aim is to achieve symmetrical configuration, to increase fused leaflet mobility, and to avoid unnecessary plication. Our group created an interactive tutorial on different BAV phenotypes repair using an internal annulus remodeling ring, focusing on postoperative gradients.11Jasinski M. Deja M. Kosiorowska K. Gocol R. Rankin J.S. Internal aortic annuloplasty remodelling ring in BAV repair- different phenotypes.Multimed Man Cardiothorac Surg. 2022; 2022https://doi.org/10.1510/mmcts.2022.039Crossref Scopus (6) Google Scholar Leaflet quality assessment and improving mobility while performing symmetrical annuloplasty can help to avoid higher postoperative gradients . Aortic root replacement with bicuspid valve reimplantation: Are outcomes and valve durability comparable to those of tricuspid valve reimplantation?The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 1PreviewTo assess intermediate-term outcomes of aortic root replacement with valve-sparing reimplantation of bicuspid aortic valves (BAV), compared with tricuspid aortic valves (TAV). Full-Text PDF Outcomes and risk factors of late failure of valve-sparing aortic root replacementThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 2PreviewRetention of the native aortic valve when performing aortic root surgery for aneurysmal disease has become a more common priority. We reviewed our experience in valve-sparing aortic root replacement (VSARR) to evaluate the long-term outcomes and the risk factors for reoperation. Full-Text PDF Predictors of long-term stenosis in bicuspid aortic valve repairThe Journal of Thoracic and Cardiovascular SurgeryPreviewThe use of modern techniques for bicuspid aortic valve repair has been shown to provide safe and durable results against recurrent regurgitation. However, an emerging body of evidence is indicating that aortic stenosis might be an additional late complication of these procedures. To date, the pathogenesis and clinical impact of aortic stenosis after bicuspid aortic valve repair are poorly understood. Full-Text PDF Well-functioning bicuspid aortic valves should be preserved during aortic replacement for the ascending aortopathy phenotypeThe Journal of Thoracic and Cardiovascular SurgeryPreviewConsensus has not been reached on whether or not to replace or preserve a well-functioning bicuspid aortic valve (BAV) in patients undergoing aortic replacement for the ascending phenotype of BAV aortopathy. We characterize morphology, evaluate progression of aortic regurgitation or aortic stenosis, and investigate the need for aortic valve replacement in patients whose well-functioning BAV was preserved during ascending aortic replacement ≥10 years prior. Full-Text PDF Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplastyThe Journal of Thoracic and Cardiovascular SurgeryPreviewWe investigated long-term outcomes of bicuspid aortic valve (BAV) repair, with external annuloplasty, according to aorta phenotype. Full-Text PDF

The observed benefit of reimplantation is evidently related to the well-documented advantage of complete, circumferential annuloplasty, effectively avoiding further dilatation. However, more detailed insight, including enhanced imaging techniques, might be required to assess annuloplasty efficacy comprehensively.

We read with great interest the article by Patlolla and colleagues 1 Patlolla S.H. Schaff H.V. Stulak J.M. et al. Bicuspid aortic valve repair: causes of valve failure and long-term outcomes. Ann Thorac Surg. 2021; 111: 1225-1232 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar providing a long-term analysis of the redo operation and failure mode after bicuspid aortic valve (BAV) repair. The study included 113 patients who underwent aortic valve repair for severe pure aortic regurgitation. Among the different repair techniques applied, annuloplasty was achieved by subcommissural plication in nearly 95% patients. Of note, all patients had BAV type 1 with predominantly left-right fusion. The authors compared aortic valve repair with mechanical valve replacement in a 106-patient cohort and bioprosthetic valve replacement in a 53-patient cohort, matched by the propensity scoring method. They observed a tendency toward better survivability after valve repair and found that the reoperation rate in patients after repair was similar to the rate after bioprosthetic valves but was significantly higher than the mechanical group’s. Bicuspid Aortic Valve Repair: Causes of Valve Failure and Long-Term OutcomesThe Annals of Thoracic SurgeryVol. 111Issue 4PreviewRepair of bicuspid aortic valves (BAVs) for aortic regurgitation (AR) has favorable outcomes, but the impact of natural disease progression on durability of repair is uncertain. We evaluated causes of reoperation and compared outcomes of BAV repair to those of patients undergoing aortic valve replacement (AVR). Full-Text PDF

We read the study by Sarafi et al. with great interest. The authors present the long‐term outcomes after bicuspid aortic valve (BAV) repair with or without root replacement. Their analysis included 142 patients, of whom 94 patients underwent isolated BAV repair and 43 patients underwent BAV repair with valve‐sparing aortic root replacement. Overall survival at 5 and 10 years was similar in both groups (p = .31). Eleven patients in Group 1 and five patients in Group 2 required reoperation of the aortic valve (p = .5). Of all patients, only three had Grade 2 regurgitant aortic valve. The cumulative risk for valve‐related complications was 2.9%/per patient‐year and 4%/per patient‐year for Group 1 and 2, respectively. Authors conclude that reimplantation with BAV repairs provides good long‐term outcomes with a low reoperation rate and durable valve function. The authors should be congratulated for the impressive 10 years of follow‐up of BAV patients. Results of freedom of redo‐operation of 77% at 10 years is a significant achievement and very supportive for recommendations. However, for better understanding, there are a few points that should probably require more in‐depth analysis. There is no mention in the article of the annuloplasty technique performed or the STJ remodeling. Circumferential annuloplasty, both external and internal can be helpful in the management of annuloaprtic ectasia, avoiding progressive dilatation, and therefore has been shown to be a predictor of durability. Different aortopathy phenotypes are also decisive when choosing different techniques of aorta management, such as reimplantation versus remodeling vs STJ remodeling with or without annuloplasty or tackling both. Moreover, breaking down these patients into different BAV phenotypes, that is, BAV 0 versus BAV 1 or degree of symmetry, may allow to better understand of the role of different mechanisms of failure. One of those factors that appear to be important is the use of patch reinforcement of the fusion leaflet. This was coincidental with long‐ term elevated gradients. Similarly, the Mayo group presented that the gradient can increase over time and may be responsible for late calcifications and stenosis. Indeed, this failure pattern was noticed by authors in 25% of redo‐operations in their paper. In very recent clinical data, it has been observed that proper annuloplasty is helpful in achieving better coaptation, especially for the asymmetric type BAV 1 or 2 or type 0 according to Sievers. This may allow the use of leaflet enhancement techniques to be dispensed with, achieving the same anatomical benefits in terms of better coaptation, symmetric leaflet apposition, and possibly low gradient. We believe that a causative analysis based on a careful pathophysiological patient breakdown into different types can help to increase the long‐term durability of BAV repair. In addition, by finding accurate timing of the surgery, we can improve reverse remodeling and avoid regurgitation recurrency and aortic enlargement. Again, we would like to congratulate Dr Holubec and his group for delivering meaningful data on the contemporary issue of BAV repair in a toolkit for routine aortic surgery.

Journal Article Unicuspid aortic valve repair—the fellowship of the ring Get access Marek J Jasinski, Marek J Jasinski Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland Corresponding author. Clinical Department of Cardiac Surgery, Wroclaw Medical University, 213 Borowska, Wroclaw 50 556, Poland. Tel: 0048 0 71 736 41 00; e-mail: marekjasinski@yahoo.pl (M. Jasinski). Search for other works by this author on: Oxford Academic PubMed Google Scholar Kinga Kosiorowska, Kinga Kosiorowska Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland https://orcid.org/0000-0002-2768-7362 Search for other works by this author on: Oxford Academic PubMed Google Scholar Mikołaj Berezowski Mikołaj Berezowski Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland Search for other works by this author on: Oxford Academic PubMed Google Scholar European Journal of Cardio-Thoracic Surgery, Volume 62, Issue 6, December 2022, ezac519, https://doi.org/10.1093/ejcts/ezac519 Published: 29 October 2022 Article history Received: 15 October 2022 Published: 29 October 2022 Corrected and typeset: 26 November 2022

The study by Christ et al. [1] reports on results of propensity-matched long-term comparison of mechanical and stentless aortic valve implantation in patients under 60 years of age. Their analysis included 158 patients with stentless xenografts and 226 patients with mechanical valves. Sixty-six patient pairs were generated by propensity score matching. Actuarial freedom from redo at 20 years was 90.4 ± 4.1% in the mechanical group compared with 45.1 ± 8.2% in the stentless group. Despite a significantly higher reoperation rate after stentless valve implantation, actuarial long-term survival after 20 years was similar in both groups (53.3 ± 6.6% and 47.0 ± 6.4% for patients with mechanical and stentless bioprostheses, respectively). The authors should be congratulated on a successful and well-conducted prospective study with 100% availability. Before drawing conclusions, however, there are several points to consider. Firstly, note that the stentless valves discussed in the study are no longer available, so to some extent, this study does not reflect on outcomes of modern stentless aortic valves and grafts. Previous generations of stentless valves have unfortunately exhibited suboptimal long-term durability, due to sinotubular junction dilatation or higher early gradients, which have been documented elsewhere [2].

We describe our approach, which is based on using an internal bicuspid annuloplasty ring not only to provide annular reduction but also to routinely achieve 180° valve symmetry. The HAART 200 ring has a circular base geometry with 180° subcommissural posts. It is sized according to the intercommissural diameter and keeps that dimension unchanged. The non-fused leaflet serves as a reference, and its free-edge length is measured with a ball sizer that predicts the required ring diameter (D): D =free-edge diameter/1.5 with transannular suturing. The ring brings the sinus-to-sinus dimension centrally to improve leaflet coaptation. More importantly, the ring remodels the fused and nonfused sinuses into equal annular segments, thereby increasing the mobility of the fused segment, facilitating its later plication. In this way, the ring establishes 180° valve geometry.

Journal of Cardiac SurgeryVolume 37, Issue 11 p. 3467-3468 EDITORIAL Unicuspid aortic valve repair—Same principles, different methods Marek J. Jasinski MD, PhD, FETCS, Corresponding Author Marek J. Jasinski MD, PhD, FETCS Professor [email protected] orcid.org/0000-0002-9989-7748 Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland Correspondence Marek J. Jasinski, Clinical Department of Cardiac Surgery, Wroclaw Medical University, 213 Borowska, Wroclaw 50 556, Poland. Email: [email protected]Search for more papers by this authorKinga Kosiorowska MD, Kinga Kosiorowska MD orcid.org/0000-0002-2768-7362 Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, PolandSearch for more papers by this authorMikołaj Berezowski MD, Mikołaj Berezowski MD Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, PolandSearch for more papers by this authorAndrzej Kansy MD, PhD, Andrzej Kansy MD, PhD Department of Pediatric Cardiothoracic Surgery, Children's Memorial Pediatric Health Institute, Warsaw, PolandSearch for more papers by this author Marek J. Jasinski MD, PhD, FETCS, Corresponding Author Marek J. Jasinski MD, PhD, FETCS Professor [email protected] orcid.org/0000-0002-9989-7748 Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland Correspondence Marek J. Jasinski, Clinical Department of Cardiac Surgery, Wroclaw Medical University, 213 Borowska, Wroclaw 50 556, Poland. Email: [email protected]Search for more papers by this authorKinga Kosiorowska MD, Kinga Kosiorowska MD orcid.org/0000-0002-2768-7362 Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, PolandSearch for more papers by this authorMikołaj Berezowski MD, Mikołaj Berezowski MD Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, PolandSearch for more papers by this authorAndrzej Kansy MD, PhD, Andrzej Kansy MD, PhD Department of Pediatric Cardiothoracic Surgery, Children's Memorial Pediatric Health Institute, Warsaw, PolandSearch for more papers by this author First published: 30 August 2022 https://doi.org/10.1111/jocs.16894Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. REFERENCES 1Sievers HH, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg. 2007; 133(5): 1226-1233. 2Matsushima S, Heb A, Lammerzahl JR, Karliova I, Abdul Khaliq H, Schafers H-J. Unicuspid aortic valve repair with bicuspidalization in the pediatric population. Eur J Cardiothorac Surg. 2021; 59: 253-261. 3ElArid J-M, Neville P, Soule N, Lefort B. Reconstruction of the aortic leaflet with autologous pulmonary artery wall. Eur J Cardiothorac Surg. 2021; 59: 269-270. 4Igarashi T, Matsushima S, Shimizu A, Ehrlich T, Karliova I, Schafers H-J. Bicuspidalization and annuloplasty provide a functioning configuration to the unicuspid aortic valve. Ann Thorac Surg. 2020; 110: 111-119. 5Aicher D, Langer F, Adam O, Tscholl D, Lausberg H, Schäfers HJ. Cusp repair in aortic valve reconstruction: does the technique affect stability? J Thorac Cardiovasc Surg. 2007; 134(6): 1533-1538; discussion 1538-9. 6Jasinski MJ, Kosiorowska K, Gocol R, et al. Bicuspid aortic valve repair, outcomes after 17 years of experience. Eur J Cardio-Thoracic Surg. 2021; 60: 1053-1061. 7Aicher D, Kunihara T, Abou Issa O, Brittner B, Gräber S, Schäfers HJ. Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation. 2011; 123(2): 178-185. 8Kari FA, Kvitting JP, Stephens EH, et al. Tirone David procedure for bicuspid aortic valve disease: impact of root geometry and valve type on mid-term outcomes. Interact Cardiovasc Thorac Surg. 2014; 19(3): 375-381. 9de Kerchove L, Mastrobuoni S, Froede L, et al. Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification. Eur J Cardiothorac Surg. 2019; 56: 351-359. 10Schneider U, Hofmann C, Schöpe J, et al. Long-term results of differentiated anatomic reconstruction of bicuspid aortic valves. JAMA Cardiol. 2020; 5(12): 1-8. 11Danial P, Neily A, Pontailler M, et al. Ross procedure or complex aortic valve repair using pericardium in children: a real dilemma. J Thorac Cardiovasc Surg. 2022; 163: 1180-1191. 12Pizarro C. Aortic valve intervention in children: the jury is still out. J Thorac Cardiovasc Surg. 2022; 163: 1192-1193. 13Buratto E, Konstantinov I. Aortic valve surgery in children: repair now, Ross procedure later. J Thorac Cardiovasc Surg. 2022; 163: 1193-1194. 14Jahanyar J, Aphram G, Munoz DE, et al. Congenital unicuspid aortic valve repair without cusp patch augmentation. J Card Surg. 2022; 37: 1-4. doi:10.1111/jocs.16622 15Jasinski M, Deja M, Kosiorowska K, Gocol R, Scott JR. Internal aortic annuloplasty remodelling ring in bicuspid aortic valve repair: different phenotypes. MMCTS. 2022. doi:10.1510/mmcts.2022-039 16Si M, Conte J, Romano J, et al. Unicuspid aortic valve repair using geometric ring annuloplasty. Ann Thorac Surg. 2021; 111: 1359-1366. doi:10.1016/j.athoracsurg.2020.04.147 17Svensson L, Al kindi A, Vivacqua A, et al. Long-term durability of bicuspid aortic valve repair. Ann Thorac Surg. 2014; 97: 1539-1548. 18Shraer N, Berrebi A, Biondi R, Lansac E. Bicuspidization of a unicuspid valve using sliding plasty of a rudimentary right coronary cusp. Eur J Cardiothorac Surg. 2022; 62(3):ezac360. doi:10.1093/ejcts/ezac360.PMID:35766794 Citing Literature Volume37, Issue11November 2022Pages 3467-3468 ReferencesRelatedInformation

Journal Article Assessment of aortic annuloplasty techniques—is the jury already in? Get access Marek Jasinski, Marek Jasinski Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland https://orcid.org/0000-0002-9989-7748 Search for other works by this author on: Oxford Academic PubMed Google Scholar Kinga Kosiorowska, Kinga Kosiorowska Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland Corresponding author. Department of Cardiac Surgery, Wroclaw Medical University, Borowska 213, Wroclaw50-556, Poland. Tel: +48-717334100; e-mail: kosiorowska.kinga@gmail.com (K. Kosiorowska). https://orcid.org/0000-0002-2768-7362 Search for other works by this author on: Oxford Academic PubMed Google Scholar Mikołaj Berezowski Mikołaj Berezowski Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland Search for other works by this author on: Oxford Academic PubMed Google Scholar European Journal of Cardio-Thoracic Surgery, Volume 62, Issue 2, August 2022, ezab569, https://doi.org/10.1093/ejcts/ezab569 Published: 29 December 2021 Article history Received: 28 September 2021 Accepted: 21 November 2021 Published: 29 December 2021

We have read with great interest the article by Papakonstantinou et al. providing a single-center analysis of the contemporary approach to tricuspid aortic valve (TAV) insufficiency with the use of HAART 300 annuloplasty ring [1].We believe that the presented concept of a robust circumferential aortic annuloplasty with separate sinus replacement, avoiding coronary re-implantations when allowed, can be successfully applied to many cases, including BAV.

OBJECTIVES: This study presents the results of 17 years of experience with bicuspid aortic valve (BAV) repair and the analysis of factors associated with repair failure and early echocardiographic outcome. METHODS: Between 2003 and 2020, a total of 206 patients [mean age: 44.5 ± 15.2 years; 152 males (74%)] with BAV insufficiency with or without aortic dilatation underwent elective aortic valve repair performed by a single surgeon with a mean follow-up of 5 ± 3.5 years. The transthoracic echocardiography examinations were reported. Presented at the 34th Annual Meeting of the European Association for Cardio-Thoracic Surgery, Barcelona, Spain, 8–10 October 2020. C O N V EN TI O N A L A O R TI C